NUR 242 Medical-Surgical Nursing Concepts

NUR 242 Medical-Surgical Nursing Concepts

Exam 3

Question:

The nurse is assessing a patient with a chest tube following a pneumonectomy. Which assessment finding requires intervention?

• Bandage around the posterior tube is loose.
• 2 cm of water is in the second chest tube chamber.
• The water in the water seal chamber rises and falls with

inhalation/exhalation.

• Bubbling present in the water seal chamber when the patient coughs.

Answer: A

After lung surgery, two tubes, anterior and posterior, are used. Dressings around the wound should not be loose. The wounds should be covered with airtight dressings.

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Question:

A home health patient with a history of asthma is having shortness of breath.The nurse discovers that the peak flowmeter indicates a peak expiratory flow (PEF) reading that is in the red zone. What is the priority nursing action?

• Call 911 immediately.
• Take the patient's vital signs.
• Notify the patient's prescriber.
• Repeat the PEF reading to verify the results.

Answer: A

A PEF reading in the red zone indicates a range that is 50% below the patient's personal best PEF reading and indicates serious respiratory obstruction requiring 911 or rapid response. Offer medications and stay with the patient. Repeating the PEF reading and taking vital signs are also important, but doing so first delays the administration of the rescue drugs and physician notification.

Question:

The patient is assessed and a blood glucose level and vital signs are obtained

upon arrival on the unit. Results are as follows:

BG—239 mg/dL BP—138/88 mm Hg HR—128 RR—36 breaths/min O2 saturation—88% (room air) Temperature—101.6º F

Which vital sign or test result requires the nurse's immediate attention?

• Blood pressure
• Respiratory rate 2 / 4

• Temperature
• Blood glucose

Answer: B

All of the patient's vital signs are abnormal. However, the most important one to report immediately is her increased respirations (and decreased oxygen saturation). Even though a diagnosis has not been confirmed, it is very important to address these problems. The patient is experiencing tachypnea.

Question:

After consulting with the provider, the following orders are received:

Full liquid diabetic diet IV fluids 1000 mL .9 NS at 60 mL/hr Oxygen at 2 L per nasal cannula Blood cultures × 3 and urinalysis Tylenol grain × every 4 hour for temperature above 101º F Cefazolin (Ancef) 1 g IVP every 8 hour

Which of the provider's orders should the nurse implement first?

• IV fluids 1000 mL .9 NS at 60 mL/hr
• Oxygen at 2 L per nasal cannula
• Blood cultures and urinalysis
• Cefazolin (Ancef) 1 g IVP every 8 hour

Answer: B 3 / 4

All of the provider's orders are very important. However, the most important one is oxygen therapy. Hypoxia is often seen with pneumonia, so it is very important that supplemental oxygen is started as soon as possible. IV fluids should be started to enhance pulmonary toileting, and the laboratory should be notified to draw the needed blood cultures. UAP can obtain the specimen for urinalysis. The blood cultures and the UA should be obtained before the IVP Ancef is administered.

Question:

The nurse understands that which of the following is the most common symptom of pneumonia in the older adult patient?

• Fever
• Cough
• Confusion
• Weakness

Answer: C

The older adult with pneumonia often has weakness, fatigue, lethargy, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is usually present. The most common manifestation of pneumonia in the older adult patient is confusion from hypoxia rather than fever or cough.

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